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} 4APPLICATION FOR WELL OR PUMP PERMIT Date <br /> NO. <br /> FOR OFFICE USE: Date Issued: ' 7, y <br /> (Complete,in Tiiplicate). <br /> THIS PERMIT EXPIRES 1 YEAR�FROM DATE ISSUED <br /> v°`^^--- � Owl <br /> APPLICATION IS HEREBY D ETO THE SAN JOAQUIN LOCAL HEALTH DISTRICT FOR A PERMIT TO PERFORM <br /> THE WORK STATED HEREON: ' THIS APPLICATION IS MADE IN COMPLIANCE WITH COUNTY ORDINANCE <br /> NO. 1862 AND RULES AND REG?LA IONS OF THE SAN JOAQUIN LOCAL HEALTH DISTRICT. ' <br /> y , <br /> RACT <br /> JOB ADDRESS/Z'ofts lg: 1 Y1l1^ L+ 644 CENSUS PHONE: <br /> OWNER'S NAME: CITY: f <br /> ADDRESS: PHONE: <br /> CONTRACTOR'S NAME: i 5 ►1kv1 LICENSE # _ <br /> WELL <br /> ST <br /> INTENDED USE: INDIVIDUAL .DOMESTIC WATER WELL I PUBLIC WATER INDUSTRIALEWATER WELL// / <br /> IRRIGATION/LIVESTOCK/AGRICULTURAL WATER WELL / /� <br /> CATHODIC PROTECTION WELL / GEOPHYSICAL WELL / / OTHER / <br /> LINES 70 PRIVY/2/d7yv <br /> NEW WELL: DISTANCE TO NEAREST: .SEPT TANK70 4-SEWER <br /> �tlA/n-_OTHERT NN't-e , <br /> SEWAGE DISPOSAL FIELD �� CESSP001. <br /> REPAIRS: TYPE OF REPAIRS: , <br /> ABANDONMENT/DESTRUCTION: ` METHOD T0' BE USED: <br /> PLOT PLAN: SHOW ON REVERSE SIDE <br /> k <br /> HAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DOBE IN <br /> 4 ACCORDANCE WITH THE PROVISIONS OF THE LAWS OF THE STATE OF CALIFORNIA, THE ORDINANCES OF THE <br /> COUNTY OF SAN JOAQUIN, AND THE RULES AND REGULATIONS OF THE SAN JOAQUIN LOCAL HEALTH D`ISTRICT. <br /> rE ' CONTRACTOR: <br /> �- SIGNED: <br /> t FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> DATE: ✓! <br /> APPLICATION ACCEPTED BY: <br /> 1 ADDITIONAL COMMENTS: <br /> h1 F <br /> PHASE-.II ' <br /> q, . p <br /> N BATE .. INSPECTION BX s ,DATA 1 <br /> INSPECTION BY: — - 1/72 <br /> E H 1426 y SAN JOA GIN LOCAL'HEALTH DISTRI <br /> - PINL{..CONTRACTOR <br /> -DISTRIBUTION: WHITE-HEALTH DISTRICT - YELLOW-PROPERTY OWNER <br />